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Zero tolerance culture can prevent ED violence
[Editor's note: This article is the first in a two-part series on preventing violence. In this story we examine the keys to a zero tolerance policy. In next month's issue, we will discuss key recommendations from the Occupational Safety and Health Administration and the importance of communicating effectively with patients and their families.]
Little progress has been made in curbing violence against ED nurses, asserts one behavioral expert, who says that the problem will continue to be a challenge until ED managers and hospital administrators adopt a policy of zero tolerance.
Exactly what does that term mean? "It means agreeing that no level of violence is acceptable, and that there is some consequence for every act of violence that occurs," says Jean Henry, PhD, an assistant professor of health science at the University of Arkansas, Fayetteville, and co-author of a chapter titled "Prevention of Workplace Violence," in the book Leadership and Nursing Care Management (W.B. Saunders, 2010.)
Part of the problem is that we often think of violence as falling into three obvious categories: verbal abuse, i.e., cursing at someone; yelling, i.e., adopting an aggressive tone; or actual physical assault, she says. "However, between those three can be threatening gestures physical things that are done without making contact," Henry notes. "Someone may make a scowling face or simply move toward you."
Those types of acts also must be included in your zero tolerance policy, she says. "What's more, verbal abuse can be subjective," Henry says. "Some may wish to include choice of words or tone of voice."
A successful approach to preventing violence in the ED starts with having a formal plan that lays out many of the definitions outlined above, Henry says. "You have to have things in writing," she says. "If it is not formalized, people will not take it seriously."
The ED manager's first order of business should be prevention, followed by a description of responses, Henry says. Prevention incorporates security, safety, and surveillance, she says. "Cameras are obvious. People can see them," Henry says.
Cameras and/or closed-circuit video should be placed in all open public access areas of the ED, with particular attention to waiting areas, intake desks, and other non-treatment areas of interface between staff and patients, says Henry. "Public safety should be considered a higher priority than privacy in these situations," she says. Henry adds that security cameras can be a costly option, depending on the type of surveillance equipment selected. "Some facilities outsource this aspect of security," she notes.
Staffing is another issue that managers must address, Henry says. "You should also have adequate staffing to accommodate what you know to be a heavier load on certain days or times of days," she says.
Change the physical environment of the ED, if necessary, "so it looks like a pleasant place to be if you're stranded there for hours," she recommends.
Henry cites the following suggestions by the Occupational Safety and Health Administration (OSHA), found www.osha.gov/Publications/OSHA3148/osha3148.html, for changing the ED environment:
All of these prevention steps convey the message that your ED is a place that above all else is trying to prevent violence, Henry says.
Implementing a risk management system also is a critical component of violence prevention, says Henry. "This involves a work analysis, looking at staffing patterns, different staff duties, where people are stationed, how the furniture is arranged, access entry points, security measures, cameras, who's on duty, and so forth," she explains. "All these things can put you at risk if they're not done correctly."
Mandatory training for staff
Staff education also is critical, adds Phillip Knotts, RN, administrative supervisor of nursing at Patient's Hospital in Pasadena, TX. "We started [a violence prevention] program the first of this year," Knotts says. "We sent all staff to mandatory inservices because of rising violence."
The program, facilitated by an in-house educator, included the need for staff to work together professionally and how to handle family and patients when they get disturbed. ("In the ED, preventing violence is a whole 'nother thing, with the turnover of new patients all day every day and people coming in already upset," says Knotts. "We covered how to focus family members on the problem on what we're trying to do for the patient.")